5124.193
Exception reviews of resident assessment data.

(A)
The department of developmental disabilities may,
pursuant to rules authorized by this section, conduct an exception review of
resident assessment data submitted by an ICF/IID provider under section
5124.191 of the Revised Code. The department may conduct an exception review
based on the findings of a medicaid certification survey conducted by the
department of health, a risk analysis, or prior performance of the
provider.

Exception reviews shall be conducted at the ICF/IID by
appropriate health professionals under contract with or employed by the
department. The professionals may review resident assessment forms and
supporting documentation, conduct interviews, and observe residents to identify
any patterns or trends of inaccurate resident assessments and resulting
inaccurate case-mix scores.

(B)
If an exception review is conducted before the
effective date of an ICF/IID's rate for direct care costs that is based on the
resident assessment data being reviewed and the review results in findings that
exceed tolerance levels specified in the rules authorized by this section, the
department, in accordance with the rules authorized by this section, may use
the findings to redetermine individual resident case-mix scores, the ICF/IID's
case-mix score for the quarter, and the ICF/IID's annual average case-mix
score. The department may use the ICF/IID's redetermined quarterly and annual
average case-mix scores to determine the ICF/IID's rate for direct care costs
for the appropriate calendar quarter or quarters.

(C)
The department shall prepare a written summary of any
exception review finding that is made after the effective date of an ICF/IID's
rate for direct care costs that is based on the resident assessment data that
was reviewed. Where the provider is pursuing judicial or administrative
remedies in good faith regarding the finding, the department shall not withhold
from the provider's current payments any amounts the department claims to be
due from the provider pursuant to section 5124.41 of the Revised
Code.

(1)
The director of developmental disabilities shall adopt
rules under section 5124.03 of the Revised Code as necessary to implement this
section. The rules shall establish an exception review program that does all of
the following:

(b)
Requires a written summary for each exception review
that states whether resident assessment forms have been completed
accurately;

(c)
Prohibits each health professional who conducts an
exception review from doing either of the following:

(i)
During the period of the professional's contract or
employment with the department, having or being committed to acquire any direct
or indirect financial interest in the ownership, financing, or operation of
ICFs/IID in this state;

(ii)
Reviewing any provider that has been a client of the
professional.

(2)
For the purposes of division (D)(1)(c)(i) of this
section, employment of a member of a health professional's family by an ICF/IID
that the professional does not review does not constitute a direct or indirect
financial interest in the ownership, financing, or operation of the
ICF/IID.